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Complacency putting Canadian health care at risk

As the United States attempts to overhaul health care and improve access for more of its citizens a US Senate committee recently met in Washington and invited several international experts to share perspectives on their own health care systems. Toronto physician Dr. Danielle Martin very nicely represented the Canadian perspective. It was an articulate presentation of Canadian health care. The smug Senator sitting opposite her clearly had some pre-conceived ideas about the Canadian health care system and had already formulated in his mind what he wanted to hear. Overestimated stories of Canadians going to the US for health care were offered as a rebuttal. The full exchange can be viewed. It is the aftermath of this interview, widely shared over the Internet, that I found most striking. There was much fist pumping and flag waving about how a Canadian doctor took on a mighty US Senator in an entertaining smack down. It was a patriotic reaction that would not have been out of place a month earlier in Sochi. Certainly Dr. Martin did not pretend to say our system is perfect and acknowledged improvement is needed. Unfortunately that message was lost in the noise.

The day before, on this very site, a very different picture of the Canadian health care was presented. The story of a young Alberta man was highlighted. Greg Price died from complications of testicular cancer after a very delayed diagnosis. A review of Price’s clinical course exposes a number of inefficiencies and gaps in our health care system. I was struck by how a thoughtful examination of why our system needs fundamental improvements to make care better for patients was drowned out within 36 hours by the public reaction to the spectacle from Washington.

Our publicly funded health care system is in my mind something that should be cherished. A system that is accessible to all of its citizens strikes me as a fundamental human right, especially in an affluent country such as ours. Canadians have a lot to be proud of. Our patients do not have to worry about whether they will become financially burdened by expensive medical care and providers and hospitals are not burdened with large accounting departments. Given the need to be careful with resources, physicians I think can better provide medical advice according to best evidence. Marketing forces influence clinical care much less in Canada. Our operating rooms are always full. Walt White’s “Breaking Bad” character may have made different choices had he lived in Canada. Finally, our physicians and health care providers are highly respected around the world as thought leaders and have always led many medical advances, from the discovery of insulin to advances in transplantation surgery and cancer care.

However I think complacency puts Canadian health care at risk in 2014. We cannot simply be content to define ourselves as not-American without a clear attempt to understand where we can improve. There are many things we can learn from other countries. The contrast between Martin’s testimony and Prices’ experiences highlights this. Ontario hospitals have generally operated with close to a 0% budget increase over the last four years. This is despite the rising cost of technology and labour as negotiated by collective bargaining. A recent report by the Fraser Institute attempted to quantify the financial costs that patients absorb waiting for care. Of course, spending more money on our system is not the simple answer. We need to find ways to make it more efficient, innovate constantly and encourage partnerships across institutions.

Testicular cancer is a highly curable disease if managed quickly. A number of specific recommendations Health Quality Council of Alberta were made in the wake of Greg’s experience. In my own experience as a urologist my clinic is always booked and OR time filled. Despite that there is a regular stream of patients like Greg that enter my care. The task of moving them through quickly and expertly must always be front of mind. Certain aspects of healthcare cannot be commodified. There is a significant responsibility placed on health care providers to be proper stewards of our system

Certainly as we move forward we should justifiably be proud of the health care system we have created but must understand that the delivery of modern health care is a complex challenge that will require broad consultation between physicians, health care providers, administrators and government with a vision that looks beyond the rhetoric and four year election cycles. As Greg’s case highlights we need to take individual ownership as physicians to advocate for our patients. Celebrate what we have but strive to make things better.

Rajiv Singal is a Urologist at Toronto East General Hospital and an Assistant Professor in the Department of Surgery at the University of Toronto. Follow Rajiv on Twitter at @DrRKSingal

Enter the debate: reply to an existing comment

35 comments

Manuela FilekMay 12th, 2014 at 2:34 pm

I am thankful for my health care system. However, I think our health care system has too many administrators and government officials not knowing what they are doing and throwing too many road blocks preventing doctors and families from advocating for patients and loved ones.

I went to school in the US and was shocked at how little the average US citizen knew about what occurred outside their borders. University grads who thought that WW2 started in 1941 as just one example.
Far too many of them really believe that if IT didn’t come from the USA then it couldn’t be very good.
All that being said, in my opinion, our medical system is falling not advancing. We continue to be at the forefront of new processes but the treatment for the average person is getting worse. Our hospital system is relying far to much on public donations.
The quoted example of the delay in diagnosing Greg’s testicular cancer is becoming far to common. Most other treatments are like this-Orthopedic appointments and operating surgery would be another typical example.
Our system seems to be caught in a nasty spot as medical costs keep on going higher and there is less monet supply to offset these demands.

To reduce the long term demands on our health care system, we need a better educated – medically aware citizenry. This should come through enhanced education beginning in primary school and being extended through high school and perhaps beyond. Only positive behavioral change fostered through public education can turn the tide against the crippling onslaught of chronic diseases like diabetes, obesity and all the ancillary problems they cause. Cheers and ciao DGF

This is a very nuanced and thoughtful commentary about the strengths and weaknesses of diverse delivery systems, and the implications of different models for quality and access, among other concerns. Thanks for sharing this perspective.

Rajiv, great article from someone that absolutely cares for his patients, many thanks.

I live 3+ months in Fort Myers, some conversations during social hours do touch on medical issues, advantages and disadvantages Canada vs US. As you state, often the exception becomes the headline and all because change is not good in many eyes. Many of the decision makers have enough coin to have whatever medial attention they should need and anywhere they choose.

On the US side, we attended a musical benefit in Kentucky 4 years ago. A local man sold everything to try to save his wife. He had played with stars such as Dolly Pardon yet with all his skill and friends lost everything, everything, he was broke. I prefer Canada’s standard, thank God for it.

A a 2 time cancer survivor I feel qualified to comment on the efficacy of the Canadian health care system. It is terrific in terms of diagnosis and treatment – fast and effective.
My one disappointment was in respect to the quality of nursing. I have been a ‘guest’ at two Toronto-located hospitals and in both instances found the professionalism and attitude of the nursing staff to be inconsistent. Their are many excellent nurses, but also too many that are going through the motions and a minority that appear to be on a power trip. Part of this may be due to a unionised work environment, part may be due to ineffective employee performance reviews and part is due to the uncomplaining customers (I include myself) who are at their most vulnerable and just want to put the experience behind them.
Perhaps a scorecard process whereby all discharged patients have the option to score individual nurses on their care would help – but would the Unions agree?????

As a Canadian transplant in Los Angeles, I think this article is right on the money. Close family members of mine in Ontario have had some health issues recently, and have encountered some of the downsides of the Canadian system — specifically, longer waits for treatment, & problems when their primary physicians retired. I’m still a bigger fan of the Canadian system, having dealt with both, but I think Dr. Singal’s thesis of “Let’s be proud but still strive to improve” is both very sound and extremely well expressed here.

Thank you for sharing your thoughts so well, Dr Singal. Every heath system has its strengths and weaknesses. It’s difficult to balance access, quality and costs when so many things are changing. Identifying opportunities for improvement requires constant vigilance and action. Thanks for the reminder.

I have had many discussions with myUS colleagues about our health care system. I am proud to be a Canadian and feel fortunate to be able to access care when needed. However, our system is more of a “sick care system” meaning that preventive medicine (which could reduce long term costs) is not being practiced fully. Once we get “sick” then the system kicks in.
Case in point, the area of treating Sleep Disordered Breathing (otherwise known as Obstructive Sleep Apnea) is responsible for many co-morbidities e.g. hypertension, stroke, metabolic syndrome just to mention a few. This is an area where dental intervention could be part of a preventive program in controlling these co-morbid diseases.
This is a great topic that needs constant review and modifications.
Rajiv, thanks for starting a dialogue

As Canadians we are, and should be, greatful for a healthcare system that is world renowned, innovative and accessible. We also should continue to look for ways to improve it as our demographics and ensuing needs continue to change. Recently I visited the ER with excruciating pain – having been previously diagnosed with kidney stones and presenting all the typical symptoms- I felt things would progress efficiently. In reality it took several hours before I was seen by a dr -as there was only one manning the ER. After looking at the bloodwork and urine sample it was determined that I “might” be passing a kidney stone. I was sent home with antibiotics ( though there was no sign of infection) and T3’s and told to contact my family Dr to schedule an ultrasound. As it turns out the next available ultrasound appt was almost weeks away. I was Left to suffer considerably until the stone passed. I feel certain that things could have been dealt with more efficiently if while at the ER they had investigated the obvious. Why couldn’t the ultrasound or a CT scan have been given to confirm the problem and a plan of action been set up? Why was I deferred back to my family Dr without a diagnosis or treatment plan given? I believe this is a common experience for people visiting the ER. Certainly this is an area where some changes need to be made in order to make it more efficient use of our time and resources.

Thank you for the thoughtful appraisal of the Canadian Health Care System. We need more medical health practitioners like you to guide the discourse about health care reform in this country. We hear far too much of the rhetoric that characterizes the American debate about Medicare and Obamacare. I completely agree with you that we should start from the assumption that accessibility for all Canadians must stand as a fundamental human right. Our descendants may have created universal health care, but it now falls on the shoulders of all stakeholders in this country to maintain it. As you pointed out, we cannot remain complacent about our past successes. Efficiency, innovation and new partnerships have helped to keep costs down. But more needs to be done to keep the medical health system in Canada viable.

I’ve had similar debates with Americans where I try to address the misunderstanding that socialized medicine is dangerous and unhealthy. While I’m proud of the system we have in Canada for the most part, my mother has been put on a 16-month waiting list for a knee replacement that everyone agrees she needs. But when my father had two massive heart attacks his care was instant, world class and free to our family. We have a great system but it’s strained.

The fact is that healthcare in the developed world has become a massive industry with Big Pharma focused on creating consumables (drugs and treatments) that treat the symptoms and not the cause. Likewise it’s all about profit for insurance companies whose profit is directly proportional to how little money they spend caring for others.

I spoke with a medical equipment technician employed by a Halifax hospital who pointed out that he could replace a broken transistor in a $75,000 piece of monitoring equipment with a perfectly good and new $1.99 transitor from a local electronic shop but the manufacturer voids the warranty on any repairs that don’t use their parts. The cost for the manufacturer’s transistor? $175.00!

As long as we keep pumping our healthcare dollars into a system controlled by the profiteering and predatory business practices of industrialists who capitalize on the sick, we’re fighting a losing battle. Our best bet at maintaining a strong health care system is to change our perspective to reduce waste where there’s already plenty but, most of all, we need to stop reacting to illness and start proactively embracing wellness. The answer isn’t to give inferior care to more people. The answer is to create fewer customers for the healthcare industry in the first place by embracing wellness.

Diabetes is going to be at the root of a major health crisis in the coming years and it is a completely preventable disease. Instead of proactively changing our behaviors to prevent becoming diabetic you can bet Big Pharma will develop expensive diabetes treatments and insurance companies will adjust insurance rates to mitigate the risk to their profitability.

A society focused on wellness could greatly reduce the strain on a buckling healthcare system. It requires education, awareness, and the political will though I’m not sure we’ll get there as a society.

Dave: I think your comments are particularly valid. Without embracing disease prevention and wellness we are always reacting. I do think though that capital from various sources could be of value. The key is trying to find that overarching vision to make it so. Need an authority with enough clout and political capital to ensure integrity. Very difficult when there are so many competing incentives. Certainly cant happen when we are reduced to self-congratulatory behaviour as in the story above. As I said , need to think beyond election cycles and we need to understand that we are not very competitive in many domains

Great article Rajiv. There is a bit of a continent centric (in the geographic, not urologic sense) viewpoint of health systems in these debates. We should look beyond the US in comparing our system and get past Canadian healthcare exceptionalism. There are many examples of combined systems that still uphold what most would consider core Canadian values under the Canada health act. Interestingly in Australia’s budget today a $7 gp copayment was introduced and $5 of that is supposedly going to build a planned $20 billion medical research fund. The spin doctors here touted it as the cost of two flat whites.

Thanks Brian. Looking beyond our North American borders would be particularly insightful. Need political and medical leadership to drive this. I think we should embrace trying to get Canadian health to be exceptional. We are clearly not there yet

Many valid issues have been raised here. There seems to be an obstinacy to discussion of health care in Canada as if this would lead to destruction of what now exists. We are all responsible both providers and consumers of health services to use them prudently and efficiently otherwise the costs on an aging population will be unsustainable. It seems that discussing effiencies and possibly co-payments in some circumstances leads to an irrational fear that we will “lose” something whereas not doing so might be the real catalyst of loss. My experience with the health system is exemplary and impressive. I have received courteous, timely and appropriate treatment every single time. I live without fear that any future medical need will not be available for any reason. This affords me to be stress free with regards to health which in turn leads to a healthier more enjoyable life. Diagnosis of potential fatal conditions should have top priority in our system. I strongly believe that the whole gamut of service providers should have constant dialogue as how to improve and retain our system.

A good article, but unfortunately resonates with the all-too-familiar tones of ‘our system is better than your system’. One cannot deny that there are many benefits to both – the innovation that comes from the US, the access available to Canadians. Unless we in Canada can overcome the political stigma of private healthcare in conjunction with our existing system of public access we will continue to have to rely on the best efforts of doc’s and others to do what is right. Best efforts however can have unfortunate consequences when dealing with life and death situations. By allowing private offerings of health care many patients will voluntarily remove themselves from public waiting lists and other healthcare resource allocations. It seems like we have two choices: pour more money into the existing healthcare system and hope that works, or do something different i.e. more efficiently, that does not draw more heavily on taxpayers. I understand that the objection to this is that rich people will get better health care than poor people, but this can be avoided through proper standards and procedures, in fact no different from what’s being done right now. Rich people will have more options, that’s true, but rich people have more options with respect to food, housing, clothing, vacations, etc. It is indeed unfortunate that no governing political party will step to the fore to take this on. Maybe the doc’s themselves should push for this. It’s your industry, guys.

Thank you Dr. Singal for your insight into this topic, and for the terrific prostate surgery done by you, your team, and all those involved from Toronto East General Hospital. As a Canadian, and a resident of East York, I am extremely proud of our Canadian health care system, and proud that Toronto East General Hospital is our neighbourhood hospital. I’ve had a number of surgeries there, and it’s great going shopping at the local supermarket and bumping into staff and being able to thank them for their great work. I think all of the surgeons who have helped me have studied medicine here in Canada, and most, if not all, also teach here. We as a nation should be extremely proud of our health care system. I’ve lived in other parts of the world, and at 50 and in good health, believe we have the best health care system on the planet! It’s one thing I don’t have to worry about!

Spot on – be proud of what we have but realistic about our limitations as to not become blind to the need for improvement. Too much of the patriotism for our health system comes from a direct comparison to the fledgling U.S. There are much better system comparators and leading practices from other countries that we should be looking to for inspiration and ideas. Looking beyond our closest neighbour might actually help keep Dr. Martin’s secondary message from getting lost in the noise. Maybe we need a Swedish doctor gave our politicians a smack down about how our preventable death rate is higher than theirs or a Japanese doctor to point out that our infant mortality rate is twice their rate. Perhaps then we will be able to look beyond our patriotism and have a mature conversation on our real performance and how we can do better.

Thank you Dr. Singal for this call for less complacency about Canadian healthcare. However, I wish there were more to be proud of. I think there is little doubt that some aspects of Canadian healthcare are “World class” (as is the case in the US, too). But our overall results in any international comparisons of healthcare “outcomes” (Euro-Canada Health Consumer Index, World Health Organisation, The Commonwealth Fund) show us in a very poor light, particularly compared to Continental European countries (that also provide universal healthcare). In such studies we do achieve better results than the USA but this is cold comfort when we ranked 15th out of 15 compared to Europeans in the last Euro-Canada Health Consumer Index, 12th out of the same 15 in the last World Health Organisation report and 4th out of the 4 countries in this group covered by the 2010 report from The Commonwealth Fund.

When our healthcare spending per capita is mid-pack to high in relation to the comparison group (excluding the USA), this should be of particular concern. It demonstrates that we are not deploying existing resources anything like as effectively as other, comparable Western countries (the US again excluded). I don’t think we should be gloating about being better than the worst!

The OECD recently released a report, “Health at a Glance 2013 – OECD Indicators”. With 2.4 doctors per 1,000 population Canada ranked 30th out of 41 countries with 25% fewer than average. The shortfall from Continental European countries is even greater. In terms of hospital beds per 1,000 population, Canada ranked 32nd (out of the 41) and hospital bed occupancy levels were the 4th highest. This report provoked a front page headline the UK’s “The Daily Telegraph” – “Hospital bed shortage exposed – UK has the second lowest number of beds per person in Europe … as overcrowding breaches safety limits and raises the risk of superbugs”. Canada has fewer hospital beds and higher occupancy rates than the UK! (There are other, equally worrying statistics in this OECD report.|)

This does lead one to question how it is that Canada spends so much (per capita) and yet produces so few essential services and facilities compared to comparable countries with universal healthcare.

Perhaps the answer lies in the following observations provided as “speculation” in the Euro Health Consumer Index 2012 report: – “one important net effect of the (Netherlands) healthcare structure would be that healthcare operative decisions are taken, to an unusually high degree, by medical professionals with patient co-participation. Financing agencies and healthcare amateurs such as politicians and bureaucrats seem father removed from operative healthcare decisions in the (Netherlands) than in almost any other European country. This could in itself be a major reason behind the (Netherlands) landslide victory in the EHCI 2012”; and “Looking at the results of EHCI 2006 – 2009, it is very hard to avoid noticing that the top consists of dedicated Bismark countries (those that provide – universal – healthcare systems built on social insurance with healthcare insurance arrangements organisationally independent of healthcare providers) … Large Beveridge systems (where financing and provision of services are handled within one organisation … as in the UK” – and Canada) “seem to have difficulties at attaining excellent levels of customer value …”

As Dr. Singal suggests “There are many things we can learn from other countries. But let’s compare ourselves to the best (with comparable resources) – not the worst!

A well spoken and thoughtful article. Having worked in both the US and Canadian systems, I can confirm that both systems have their strengths and weaknesses. I am convinced that for urgent or emergency care, the Canadian system is excellent, as good as any other one would compare it to. However, our system is incredibly strained, and the cracks are starting to show. I’m proud that in our country, nobody will lose their house or go bankrupt because a relative gets cancer and requires expensive care. On the other hand, I have always found it a bit odd that in Canada, I can buy an MRI for my dog, but not for my mom.

Given these two stark contrasts, I can say without hesitation that I would much rather have our problems than their problems. Unfortunately, we definitely cannot state that we have the best healthcare system in the world – I would echo other comments that there are many lessons we can learn from various systems in other countries.

One of the major problems is that we have two forces in stark opposition – on one side, physicians and other medical professionals are attempting to treat as many patients as they can, providing all the necessary services that are asked of them by the public. On the other, the budgetary restraints of the system effectively handcuff us to treating a limited number of people. It is not the physicians that are creating illness that requires treatment, however much hospital administration may think it.

Ultimately, I do believe that essential healthcare is a fundamental human right, and should not be treated like a business. Due to the ever-rising cost of health care, pharmaceuticals, and technology, it may be necessary to look beyond what has served us well up until this point. We can still debate whether user fees, various public-private partnerships, or other parallel types of healthcare systems can be incorporated into what we have now, without having to sacrifice the entire concept of universal health care. Preventative care and patient education will be equally as important in controlling healthcare spending. We should be proud of what we have in Canada, but like our health and the health of our patients, it won’t last forever if we ignore ways to maintain and improve it.

Powerful stuff Rajiv! I don’t know how I missed the article in the National Post or how I overlooked your first posting, but am so glad you sent it around for the second time. It will be well received in my circles (mostly seniors) where I plan to share.

2,000 years ago, Rome ruled the world. And they divided the world into 2 kinds of people: Romans and Barbarians. Of course there were both friendly Barbarians and unfriendly Barbarians. To the Romans, the purpose of Barbarians was to provide Rome with raw materials, slaves, and for friendly Barbarians, soldiers in time of war, while the purpose of Rome was to ‘Romanize’ the Barbarians. Naturally, because they were Barbarians, they received little consideration or study, nor were they treated fairly or equally. After all, they were Barbarians.

Now roll this forward 2,000 years. Does it sound like anyone we know?
Just wondering….

i am great full of the health care system that we have here in Canada, being able to walk in to the doctors office without any financial worries and knowing that you are getting a first class medical attention. personally, i just went through a major surgery and with outstanding outcome thanks to Dr.Singal’s team.i believe a proper understanding of ones problem ,risk involves and positive attitude will help the decision making process.Now, regarding the enhancing of our health care system,ones need to find the solution by decreasing waiting times by bringing more specialist to our system.We need to develop a programme that keep high standards but allows more excellent students to have access to medic schools and furthermore encourage them to continue further specialization studies. The participation of private sponsorships and governmental must join efforts towards this goal.

Ravi – Thank you for your well thought out article and an obvious commitment to improve our health care system. My own thoughts on how we need to improve the system is emphasizing the preventative side of health care. we have taken some major steps with the reduction of smoking and other negative health impacts; however, diet is one of the major impacts on Canadians health. we have an opportunity to improve health and use our health system more efficiently if we change our eating habits.It is not easy to change habits and it is as difficult to change and addictive as smoking. Government needs to play a leadership roll if we are to make real change in this area and improve the health of Canadians.

Great article Dr. Singal !! As a snowbird who has spent 5 months plus in America for the last 9 years , I’ve been involved in MANY health care discussions – I continue to believe our system has much to be proud of. By the way I saw Dr . Martin’s exchange and thought she was outstanding in a pretty hostile environment. The US system is evolving as we all know and I do think there are some positives to be learned from the “for profit ” side of things. i.e clinics providing easy access to MRI’s etc.

On balance though your comment that “marketing forces influence clinical care less in Canada” is spot on and a real strength for us. There are no magic bullets re the funding challenges but your comments re being more efficient and innovative are again right on The current aging baby Boomers are simply going to add to the funding challenges. Lots of work and creative thinking needed to be sure.

Well presented Raj.. With advances in technology, diagnostics and treatment
rushing (thankfully) at us….targeting an acceptable balance of deliverables
(Between all stakeholders) in a non-absolute environment is paramount

Adjudicating that balance is, of course, problematic and certainly cannot be
the exclusive purview of any agency. Viva the social democratic environment

Excellent article and very well written Dr Singal.
I am still amazed that in a developed country and as a world leader, the USA does not provide basic healthcare to their citizens. I have a strong circle of friends in the US and without having their own, expensive, medical insurance, there is no way they would be treated close to what we receive (not to mention higher bills and limits to their policies).

That being said, I do believe we must have some form of budget allocation to allow hospitals and their staff to keep up with technological advancements in healthcare. It costs money to do research and provide better treatments options to patients and therefore, there is a price to pay for it as well. The ability for Canada to remain a leader in the global medical landscape cannot be achieved with constant budget cuts and looking at the cheapest option to do anything.

I enjoyed the article, many good points to consider. The influence of marketing forces on clinical care in Canada vs US is an interesting topic. Although advertisements are often one sided they still educate the public of treatments physicians may not recommend. Since many Canadians learn about their health issues through web searches, it would great if Canadians had a trusted and complete source to educate themselves of their treatment options. For example if you search prostate on the Health Canada website and follow the first link to the Cancer page you will notice that it mentions that “the most frequently diagnosed cancer will continue to be prostate cancer for men” yet prostate cancer is not listed under the types of Cancer below! Care should be based on evidence and consider resources but patients should be aware of all their options domesticaly and abroad.

“Not-American” seems to sum up our most cherished feature of Medicare. We ignore all 5 principles of Medicare when it suits us: public administration, comprehensiveness, universality, portability, accessibility.

Thank you for highlighting our complacency. We could build a better system with open debate.

This document is provided under the terms of a CreativeCommons Attribution Non-commercial Share Alike license. The terms of the license are available at: http://creativecommons.org/licenses/by-nc-sa/3.0/. Attributions are to be made to HealthyDebate.ca, a project under the direction of Dr. Andreas Laupacis, at the Keenan Research Centre, Li Ka Shing Knowledge Institute of St. Michael’s Hospital.